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PAIN
Angela B.M.Tulaar
1
Definition
Low Back pain is pain felt in the region
of the lower back, that is the region between
the ribs and the hip, due to several causes,
like impairment of the musculoskeletal
system, neuromuscular system, vascular,
visceral, and psychogenic. Low back pain is only
a symptom, and not a diagnosis. Causes of low
back pain in most patients are not known.
Low back pain can be local, radicular, or both.
Pain from the lower back region may be referred to
another region, or vice versa, pain from other
region may be referred to the lower back (referred
pain).
2
Important muscles of the back
L o ng is s im us
c a pitis
I lio c os ta lis L o ng is s im us
c ervic is c ervic is
I lio c os ta lis
thora c is
S pina lis
I lioc os ta lis thora c is
lum borum
L ong is s im us
3
Important Bones and muscles
Prosesus spinosus
Latissimus
dorsi muscle
Erector
Spinae muscle
Gluteus
Maximus muscle
Posterior superior
iliac spine
Sacrum
Coccygeum
Ischial tuberosity
4
Spinal cord & nerve structure
Vertebral body Spinal cord
Pedicle L1
Conus
Pedicle L2 medullaris
Cauda equina
(dorsal & ventral)
Nerve root
Sacrum
Cauda
equina
5
C1
C2
Vertebral Region C3
C4
Cervical
C5 Vertebra
& dermatome C3
C2
C2
C6
C7
C8
T1
T2
T3
T4
T5
T6
T7
Thoracal
C5 C5
T8 Vertebra
T9
T10
C6 T11
C6 T12
L1
S3
L2
L3
Lumbal
C8 L4 Vertebra
L5
C8
C7
S1
S2 Sacral
C7 S3
S4 Vertebra
S5
Lateral view
S1
S1
6
Vertebral Ligaments Lateral view of the
Vertebral structure
Pedicle
Supraspinous Anterior
Ligament Longitudinal
Ligament
7
Articular Facet in motion Lateral Posterior
Vertebral column Vertebral column
Vertebral body Cervical Cervical
Thoracal Thoracal
Lumbal Lumbal
Sacral Sacral
Disc
Coccyx Coccyx
Flexion Extension
8
Jaringan dengan sensor nyeri
Ligamen
Posterior
Longitudinal
Diskus
Prosesus
spinosus
Nukleus
Ligamentum
Annulus
flavum
Kapsul
sendi
Korda spinalis
Saraf dan selubungnya
(Dura) 9
Axial view of the
Intervertebral disc
Annulus fibrosus Annulus fibrosus
Vertebral plate
Nucleus pulposus
Nucleus A
pulposus
Apophyseal ring
10
Clinical picture
A. Non spesific/lumbago/simple/
benign/idiopathic back pain:
Frequently seen in the age of 20-55 years
old;
The patient looks well;
Pain at the lumbosacral, hip and thigh;
Mechanical pain, varied with physical
activity and time.
11
Clinical picture
B. Radicular pain:
prognosis is fairly good, 50% improved
within 6 weeks;
unilateral foot pain is worse than back
pain;
Pain usually radiates to the foot or
toes;
Numbness and paresthesia;
Signs of nerve irritation (positive
Straight Leg Raising test /Laseque)
Local neurological signs (motor,
sensory or reflex pain)
12
Clinical picture
C. Awareness of the presence of Red
Flags (serious spinal involvement):
Age less than 20 years old or onset
more than 55 years old;
Non-mechanical pain;
Pain in the thoracic region;
History of carcinoma, steroid, and
HIV;
Looks unwell, loss of weight;
Outstending neurological signs and
symptoms;
Structural deformities;
Cauda Equina syndrome :
13
Clinical picture
Cauda Equina syndrome :
- urinary problem;
- loss of anal sphincter tone or
incontinence;
- lower extremity weakness or
walking problems;
- extensive (more than one nerve
root)
- Saddle Anesthesia
14
Neural Activation of Pain PAIN
Aδ-C
Aδ-C
Aδ-C
15
Causes of Low Back Pain
Mechanical (97%) Non-mechanical (1%) Visceral organ
disease (2%)
Strain, sprain lumbal (70%) Neoplasia (0,7%) Diseases of the Pelvic
Degenerative disc & facet Infection (0,01%) organs (prostatitis,
(10%) -Osteomyelitis endometriosis)
Disc Herniation (4%) -Epidural Absces Renal disease
Spinal Stenosis (3%) (nephrolithiasis,
-ParaspinalAbsces
pyelonephritis,
Osteoporotic Compression -Pott’s disease perinephric absces)
Fracture (4%) -Inflammatory Arthritis Aortic Aneurysm
Spondylolisthesis (2%) (0,3%)
Gastrointestinal disease
Traumatic Fracture (<1%) -Ankylosing spondylitis (pancreatitis,
Congenital Disorders (<1%) -Psoriatic spondylitis cholelithiasis)
-Reiter’s Syndrome
Paget’s disease 16
CAUSES
OF
LBP
Degenerative disease
- Disc disease
- Spinal stenosis
- Spondylitis
- Facet joint hypertrophy
17
Osteoarthritic
Articular facet
Lumbal
nerve
Degenerative
disc
Sacrum
Coccyx A
18
Degenerative spondylolisthesis
19
Spondylolisthesis
Superior articular process
Prosesus Transversus Degenerative Isthmic
Spondylolisthesis Spondylolisthesis
Prosesus Spinosus L3
Intervertebral
foramen
Pars interarticularis L4
Intervertabral
disc
Defek of the pars L5
interarticularis
(spondylolysis) Slipped spine
Anterior Displacement
of L5 on sacrum
(spondylolisthesis)
sacroiliac 1 2
Sacrum Joint surface Fracture of the
pars interarticularis
(posterior part
A of the vertebra) B
20
Lumbal Spinal Stenosis
Ligamentum Thickening of Hipertrophic
flavum ligamentum facet
flavum
Herniated disc
Nucleus
Pulposus
Annulus
fibrosus
Irritated nerve
23
CAUSES OF LBP
Neoplasma
- Primary
- Metastatic
Inflammation :
- arachnoiditis,
- arthritis,
- ankylosing
spondylitis
Severe canal stenosis
Due to facet joint enlargement
And additional soft tissue Kyphosis
24
CAUSES OF LOW
BACK PAIN
Infection
- Vertebral osteomyelitis
- Epidural absces
- Urinary tract infection
- Intervertebral discitis
25
CAUSES OF LOW
BACK PAIN
Radiculopathy
Metabolic diseases
- Osteoporosis
- Paget’s disease
- Diabetic Radiculopathy
26
iliac
bone
2 Sacrum
Sciatic
1
nerve
Sciatic
nerve 27
CAUSES OF LOW BACK PAIN
Trauma: vertebral fracture
Wedge fracture
crushed anterior part of the vertebra,
Burst fracture
Reduced vertebral height kyphosis.
If the whole vertebral Neurological damage seldom found.
body (often in osteoporosis) 28
Plain Radiograph & MRI of the vertebra
L1
1 2
A B
29
CAUSES OF LOW BACK PAIN
Trauma: lumbar sprain
and strain
30
CAUSES OF LOW BACK PAIN
Referred pain:
abdomen and pelvis
hip
31
Diagnosis
Initial evaluation of back pain is
primarily geared to remove serious
causes that need emergency.
Success of the evaluation depends on
the carefull and proper anamnesis and
physical examination.
History of the illness including the
onset, location, type and severity of
pain, factors enhancing or lessening
the pain, trauma, constitutional signs
and psychosocial stessor should be
asked.
32
History of present illness
34
Past History
Immunosupressant;
Loss of weight without clear cause (cancer);
Persistent pain is an indication for cancer or infection;
Worsening of pain (intraspinal tumor or infection) or diminishing pain
(hernia nucleus pulposus / HNP) during supine;
Worse pain in the morning (seronegative spondyloarthropathy:
ankylosing spondylitis, psoriatic arthritis, reactive
spondyloarthropathy, Reiter’s syndrome, Rheumatoid arthritis,
polymyalgia rheumatica, myofascial pain, fibromyalgia syndrome)
Pain upon sitting position (HNP, facet joint pathology, canal stenosis,
para- spinal muscle pathology, sacroiliac joint pathology,
spondilolysis/spondilolisthesis, non-spesific low back pain)
Presence of fever (infection)
Hormonal disturbance (dysmenorrhea, post-menopause/andropause)
Visceral disturbance (referred pain) 35
Neurological symptoms
disturbance in urination;
saddle anesthesia;
36
Red flags
Dangerous signs (conditions in low back
pain with serious potentials) :
cauda equina syndrome (urinary retention,
bilateral neurological signs and symptoms,
saddle anesthesia);
signs or symptoms of neurological deficits
(paresthesia, paresis and other
neurological signs);
Trauma;
loss of weight;
37
Red flags
Dangerous signs (conditions in low back
pain with serious potentials) :
fever;
use of steroids;
Extension
Flexion
Rotation
Lateral bending
41
Schober test
10 cm
15 cm
42
SLR
(straight leg raising test)
43
Physical examination
44
Sciatic nerve pathway
Sciatic nerve
45
Function & innervation of nerve roots in the lower extremity
Motoric Function
L4 L5 S1
Sensoric Function
L4 L5 S1
Medial side of the foot Dorsum of the foot Lateral side of the foot 46
Distribution of Radicular Pain
L3 L4 L5 S1
47
Radiological examinations
Radiographic examination (plain photo) of the lumbosacral
is not a routine examination, especially for patients with
simple back pain.
Lumbosacral radiologic examination may support the
diagnosis especially in the presence of history of trauma
and suspicion for infection, neoplasm, or metabolic
diasease.
Anteroposterior and lateral position is good enough to find
fracture, tumor, infection, instability, spondyloarthropathy
and osteoarthritis of the hip.
Oblique position is required to evaluate involvement of the
facet joints and pars interarticularis.
48
Radiological examinations
Radiographic examination cannot show the
presence of disc herniation or disturbance in the
muscles and ligament.
Magnetic resonance imaging (MRI) dan CT
scanning are thought for patient with
progressive neurological deficits or suspicion of
infection or neoplasm. Such examinations are
also needed in cases referred for surgery.
Magnetic resonance imaging (MRI), CT scanning
or myelography can confirm the diagnosis of
lumbal canal stenosis. Bone scanning is useful
in situations where radiographic examination
results showed abnormality in the suspicion for
osteomyelitis, neoplasm or fracture.
49
50
Electrodiagnostic examination
Electromyographic examination and nerve
conduction tests are needed to distinguish
peripheral neuropathy from radiculopathy or
myopathy. These tests are also useful in
determining the location of the lesion, the extent
of the damage, prediction for recovery and to
determine whether a structural abnormality seen
in the radiological examination is causing a
significant functional effect.
Patients with doubtful conditions and require
electrodiagnostics such as the above are referred
to the specific competent specialist. 51
LABORATORY EXAMINATIONS
Laboratory examinations like Erythrocyte
sedimentation rate (ESR), complete blood count (CBC)
and urinalysis are only requested when having doubts
for the presence of a serious underlying systemic
disease.
Increased ESR may be found in cases of infections,
neoplasm, and ankylosing spondylitis.
Anemia may be found in neoplasm and ankylosing
spondylitis.
Blood culture and Tuberculine test should be done in
suspicion of infection.
Examination of human leucocyte antigen HLA-B27 is
suggested to be done when there is suspicion for
Ankylosing spondylitis. 52
DIFFERENTIAL DIAGNOSIS
The cause of low back pain in
general may be grouped into
trauma, degenerative disease,
neoplasm, infection,
radiculopathy, metabolic, and
radiating pain
The frequent cause of low back
pain in patients coming to
physicians for consultation is
intervertebral joint dysfunction
related to trauma (72 %), while 10
% are with lumbar spondylosis.
53
MANAGEMENT
Main Objectives:
- to control pain;
- to prevent disability.
56
Pharmacological management for
Low Back Pain
paracetamol
or NSAIDs ± Chronic Pain
Adjuvant analgesics
Persistent or
Pain threshold Pain tolerance increasing pain
0 1 2 3 4 5 6 7 8 9 10
Mild Moderate Severe 58
Paracetamol and Opioid
Mechanism of action Benefit Side Effects
Paracetamol
• Inhibits synthesis of Antipyretic and Minimal to no anti-
prostaglandin in the analgesic activity inflammatory action
central nervous Well tolerated Liver Necrosis with
system (CNS)? Mild side effects overdose, alcohol users
Opioid
• Bound to opioid Effective in severe Depresed respiration
receptors, agonist pain Drowsiness, nausea,
effect inhibiting Does not cause constipation
pain impulse GI bleeding Potential for ‘abuse’
59
Non-steroidal anti inflammatory (NSAID)
Mechanism of action Benefit Side Effects
Nonspecific NSAID
InhibitsCOX-1 and Anti-inflammatory, GI,
hypertension,
COX-2 isoenzyme → analgesic, antipyretic edema, disturbance in
inhibits prostaglandin Long known efficacy renal function and
synthesis against pain bleeding
Selectively
inhibits Anti-inflammatory, GI,
hypertension,
COX-2 isoenzyme analgesic, antipyretic edema, renal effects
Milder GI side effects
60
NSAID Side effects
Gastrointestinal Peptic ulcer
Gastrointestinal (GI) bleeding
Esophagitis and stricture
Erosions of small intestines and colon
Primary sites
(Spinal cord)
of action of Eperisone
Tolperisone
several Chlorphenesin
Carbamate
muscle Baclofen
relaxants
Internuncial Neuron
Motor Neuron
(large …. α)
(small …. γ) (Skin)
(Muscle) Dantrolene 63
EVIDENCE BASED THERAPY IN
LOW BACK PAIN
68
Sit-up parsial untuk memperkuat Latihan untuk mengurangi
otot-otot abdomen peregangan otot punggung
Beberapa variasi latihan ekstensi, mulai dari yang paling ringan ditingkatkan
disesuaikan dengan kekuatan otot-otot ekstensor lumbal 69
EVIDENCE BASED
THERAPY IN LOW
BACK PAIN
Therapy with potential danger
Use of narcotic or diazepam
(especially if > 2 weeks)
Continuous Traction
Manipulation under general
anesthesia
Plaster jacket (orthoses)
70
Pilars of low back pain
management
1. IDENTIFICATION OF
RED FLAGS AND
YELLOW FLAGS
2. EDUCATION
3. ACTIVITY
4. MEDICAMENTOUS
THERAPY
5. REFERRAL
6. SURGERY
7. MULTIDISIPLINARY TEAM
71
SURGICAL INDICATIONS
Sciatic and possible Disc herniation :
*Cauda equina syndrome
*Progressive and severe neurologic
deficits
*Neuromotor deficits persistent after 4-6
weeks of conservative therapy
*Persistent Sciatica more than 4-6
weeks
72
SURGICAL INDICATIONS
Spinal stenosis :
* progressive and severe
neurologic deficits
* persistent low back and lower
extremities pain
* pain improved with trunk
flexion and related to spinal
stenosis
73
SURGICAL INDICATIONS
Spondylolisthesis
progressive and severe
neurologic deficits
spinal stenosis with the
above indications
severe low back pain or
sciatica with severe
functional impairment
persistent for one year or
more.
74
GOOD STANDING POSTURE
Head straight
Chest forward
Back straight
Abdomen tucked-in
Leg straight, or one leg
supported on a stool
Arms hanging at the
sides
75
Sikap Berdiri yang benar:
- Kepala dan punggung tegak; perut
ditarik ke dalam; lengan tergantung lurus
di sisi badan;
- Membungkuk sedikit; satu kaki
Salah
Benar ditopang
Berdiri
Sikap Duduk yang benar:
-Punggung tegak bersandar penuh; saling
menopang kaki;
-Punggung bersandar penuh; kedua kaki
ditopang di atas bangku kecil
Salah
Benar Sikap Berbaring yang benar:
Duduk
- Kepala di atas satu bantal & punggung
lurus; kedua lutut ditopang bantal;
- Tengkurap dengan bantal di bawah perut
dan kedua lengan ke atas kepala;
- Berbaring miring, siku bagian bawah
ditekuk, lengan bagian atas lurus di atas
Salah
Benar Tidur badan, bantal di antara kedua lutut 76
Mengemudi:
- Punggung bersandar penuh;
- Lutut masih tetap sedikit tekuk saat Benar Salah
menginjak rem penuh Mengemudi
Memasukkan/mengeluarkan
barang dalam/dari mobil:
- Punggung tegak, satu kaki diberi
tumpuan; Benar Salah
- Barang diangkat sedekat mungkin Memasukkan/mengeluarkan
dengan tubuh; barang dalam/dari mobil
Bekerja :
- Duduk dengan punggung tegak;
- Meja/tempat menulis sedekat
mungkin dengan tubuh
Benar Bekerja Salah
77
78
REFERRALS
For chronic low back pain of >12 weeks
multidisciplinnary team approach is
proven to be effective.
Team consists of professional health persons
trained in musculoskeletal, psychoscosial,
special treatment and related specialists
(Rheumatologist, Orthopaedics, Neurologists,
Physical Medicine & Rehabilitation Specialists,
Neurosurgeon).
Multidisciplinnary team will be able to provide
comprehensive evaluation and management
plan. 79
ALGORITME PENATALAKSANAAN NYERI PINGGANG AKUT
Ada red flags YA
Kunjungan Pertama Segera rujuk
atau yellow flags? ke spesialis
Riwayat dan
pemeriksaan TIDAK
Penilaian terhadap red
flags dan yellow flags Ikuti Panduan YA
Penatalaksanaan
TIDAK
6 minggu
TIDAK
Evaluasi ulang YA
keseluruhan PULIH ?
80